Level of care determinations will be based on interqual criteria and. Blue cross blue shield of massachusetts is an independent licensee of the blue cross and blue shield association. If the level of care is not substance use related, change healthcares interqual behavioral health criteria would be appropriate. Included in the 2015 interqual release is new acute adult level of care criteria to address comorbid conditions on admission for patients with heart failure and copd. On the description line enter interqual view 2015 f. Clinical practice guidelines are also used to guide efforts to improvement the quality of care in our membership. Interqual level of care acute criteria pediatric 2004 ringbound january 1, 2004 see all formats and editions hide other formats and editions. Hospitals frequently use level of care criteria as an objective tool to help make decisions regarding whether an individuals condition is severe enough, or the services provided are intense enough, to be admitted to a specific level of care. Sm registered and service marks of the blue cross and blue shield association. Interqual medical necessity criteria are applied to all mental health cases, medical policies, dom administrative code and milliman care guidelines. You will see a confirmation message pop up and receive a confirmation email shortly after i. Interqual level care criteria skip to main search results amazon prime.
Interqual mobile offers you aroundtheclock access to the latest. Eating disorders, j am acad child adolesc psychiatry 2015. Our four criteria suites provide comprehensive coverage for medical and behavioral health across all levels of care as well as ambulatory care planning. Download the june 2015 edition independence blue cross. Selecthealth medical criteria sets are outlined in each medical policy. Issued february interqual criteria clinical content is a synthesis of evidencebased standards of care, current. Interqual level of care criteria change healthcare. Interqual level of care criteria the interqual level of care products cover the. Interqual level of care criteria description interqual acute adult criteria help determine the appropriateness of admission, continued stay and discharge at acute care facilities for patients who are age 18 or older. Interqual level of care criteria 2010, acute care, adult. Interqual level of care criteria help healthcare organizations assess the safest and most clinically appropriate care level for more than 95 % of reasons for admission.
Implementation of the 2017 interqual criteria as a reminder, health partners plans uses mckessons interqual criteria as a guideline for making medical necessity determinations. Interqual level of care acute criteria pediatric 2004. These criteria do not replace clinical judgment, and we recognize that they require. Wellcare clinical practice guidelines reference expert professional and clinical society recommendations, ensuring that the guidelines contain the highest level of evidencebased content. Level of care criteria new york 622017, 101717 cmmc approved 3 3 inpatient psychiatric services are expected to significantly improve the members psychiatric condition within a reasonable period of time so that acute, shortterm 24hour inpatient medicalpsychiatric and nursing services will no longer be needed. Interqual level of care criteria are available for. Interqual 2015s acute adult level of care criteria helps promote care quality and minimize the administrative delays, costs, and inefficiencies. It lists changed subsets 2015 interqual criteria summary of. Charting guidelines attending physicians must write a progress note daily on a patients chart not just cosign a residents note. Retain all agreements, books, documents, papers and medical records. Vermont medicaid provider manual vermont medicaid portal.
Please note that the these are suggestions based on interqual criteria and milliman criteria used by medicare, tenncare tenncare and most of the major payers. Interqual level of care criteria the interqual level of care products cover the continuum of care. Included in the 2015 interqual release is new acute adult level of care criteria to address comorbid. Jun 21, 2007 cms does not mention interqual or any other level of care criteria in either definition.
Jan 17, 2017 interqual evidencebased criteria and technology solutions help improve clinical decisionmaking and care management across the medical and behavioral health continuums of care. Access your interqual criteria on your tablet or smartphone with a few swipes of your finger. An enhanced digital version of the interqual books, interqual mobile offers you all the benefits of a printed book without the confines of a single annual release, giving you aroundtheclock access to the latest and most accurate clinical content at your fingertips. This week we successfully resolved a technical issue that had delayed the implementation of the 2017 criteria past our originally stated october 1 target date. Criteria points are clinical statements that refer to test results, medications, symptoms, findings, monitoring, medical management, functional status, and prescribed therapies. Implementation of the 2017 interqual criteria health.
Mcg senior care strategy consultant, india watson, rn, msn, bsn. Interqual level of care acute criteria pediatric 2004 on. Please specify if you would like to receive the criteria via mail, fax, or email. The richness of clinical detail allows for consideration of. Level of care criteria interqual and internal medical policies to milliman moderate care guidelines. Rather than being based on diagnosis, they consider the level of illness of the patient and the services required. When the member has coverage for this care the skilled nursing facility admission criteria must be met for eligibility. Interqual aligns payers and providers with actionable, evidencebased clinical intelligence to support appropriate care and foster optimal utilization of resources. Select a priority level based on your timing needs d. Review of clinical information to determine if it meets criteria for medical necessity, and level of care. Interqual level of care criteria help healthcare organizations assess the safest and most clinically appropriate care level for more than 95% of reasons for admission. Level of care criteria assist organizations in assessing the clinical appropriateness of patients admissions and continued stays across the continuum of care.
Final mic report 2011 connecticut general assembly ct. Substance use lab testing criteria is in interqual behavioral health criteria. Interqual quick reference guide for admissions quick source learning quick source learning quick reference guides and computer based training, quick source interqual isd criteria. If 14 above are not met, beacons national medical necessity criteria would be appropriate. This new criteria allows for appropriate admission of medically complex patients with comorbid conditions who may not otherwise meet criteria for the primary condition alone. Utilization management case management study guide. American psychiatric association 168th annual meeting may 18, 2015. Criteria are also available upon request by calling 8004425305. Verify that the contact information listed for you is valid g. Magellan uses mcg care guidelines, along with its proprietary clinical.
Medical necessity in considering coverage for any level of care, all elements of. Interqual andor milliman training for individuals case. Interqual level of care criteria 2010, acute care, adult on. Mckesson interqual level of care criteria 20 ringbound january 1, 1900 by mckesson author see all formats and editions hide other formats and editions. Price new from used from ringbound, january 1, 1900 please retry. Care guidelines from mcg provide fast access to evidencebased best practices and care planning tools across the continuum of care, supporting clinical decisionmaking and documentation as well as enabling efficient transitions between care settings. If guidelines are met, the requesting provider is notified of the. Robertson andor interqual and some internally developed 2015 service authorization report.
To access your interqual content for use with interqual mobile, you will need to enter your interqual criteria licensing credentials. Interqual actionable evidencebased criteria portfolio. Interqual mobile offers you aroundtheclock access to the latest and most accurate clinical content at your fingertips. Criteria points support the reasons or indications. Thanks to the wide availability of the internet all over the world, it is now possible to instantly share any. Level of care criteria interqual and internal medical policies to. Inpatient and surgical care milliman careguidelines. The conditionspecific format presents evidencebased interventions that are specific to the condition and help to costeffectively improve outcomes. Care guidelines for evidencebased medicine mcg health.
The reference to the mckesson interqual level of care criteria edition updated from 2014 to 2015. Apr 24, 2014 i have searched high and low for a class on interqual but have been unable to find one so far. Level of care criteria interqual criteria are set of measurable, clinical indicators, as well as diagnostic and therapeutic services, that reflect a patients need for hospitalization. New and enhanced content is a hallmark of the interqual annual release. For example, the interqual criteria sets for see a random page in this book. The level of care criteria that follow are guidelines for determining medical necessity for the. Apr 16, 2020 access your interqual criteria on your tablet or smartphone with a few swipes of your finger. Interqual level of care criteria 2010, longterm acute care, adult.
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